Hepatitis C virus (HCV) is a widespread viral infection of the liver and a major healthcare concern, being underdiagnosed in most cases, due to its frequently asymptomatic clinical course. There are 150 to 200 million people worldwide diagnosed with HCV infection and 3 to 4 million become infected annually. It is one of the leading blood-borne infections in Europe.¹ Except for an ongoing screening study, we have no precise estimation of the total number of people infected with hepatitis C virus (HCV) in Romania, but historical research indicates a prevalence of 3.23% in the total population, of which about 80% are in the chronic phase.² The infection is mainly transmitted parenterally, and about a third of the infected patients develop liver cirrhosis in 20 to 30 years after contamination, and some also develop hepatocellular carcinoma. Twenty percent of the infected patients may present spontaneous viral clearance, without requiring treatment.³ With the previous standard treatment, which consisted in alpha peg-interferon and ribavirin, there was a risk of 23% of developing liver cirrhosis, 13.2% of liver carcinoma and 4.6% of liver transplant. However, this treatment was associated with limited adherence, which also impacted its efficacy. Previous studies showed that the main factors that limited adherence were difficulties in treatment administration and its side effects that associated a decrease in the patients’ quality of life.⁴

The study of the genetic structure of HCV has led to a clear view of the viral lifecycle and has facilitated the discovery of direct-acting antiviral drugs (DAAs). The concurrent inhibition of RNA-dependent RNA polymerase offers added efficacy to HCV protease inhibitors and this has opened the door to interferon-free regimens, particularly since viral proteins play important roles in establishing infectivity, intra-cellular signaling, viral persistence, host cell apoptosis and host cell gene expression.⁵

Our study aimed to evaluate patients’ adherence to peg-interferon and ribavirin treatment that was still the gold standard at the time when this study was designed, using an innovative model of assessment in order to improve the adherence to treatment.⁶

This was a single center non-interventional prospective study, developed in Romania (National Ethics Committee approval 993 from 03 May 2012), designed to evaluate adherence to peg-interferon and ribavirin treatment in patients with chronic viral hepatitis C, and the evolution of their quality of life during treatment. It consisted of 1 year of monitoring for each patient (2012-2013) plus a follow-up evaluation 24 weeks after the end of antiviral treatment. Patients received peg-interferon and ribavirin, which was the standard therapy for chronic hepatitis C in Romania at the time when the study was conducted. The primary objective of the study was to evaluate patients’ adherence to antiviral therapy and to assess the success rates of hepatitis C treatment with peg-interferon plus ribavirin through aggregating the data from 24 and 48 weeks. The secondary objectives were to identify the patients` perception of antiviral treatment, as well as the evolution of laboratory test results, including the rate of response to treatment, namely the sustained viral response (SVR). Inclusion criteria were: (a) adult patients, male or female gender, aged between 18-65 years; (b) patients having chronic infection with hepatitis C virus, (c) patients for whom antiviral treatment with peg-interferon and ribavirin was considered useful based on clinical judgment (both naïve and previously-treated patients, meaning patients with a viral relapse). Exclusion criteria were: (a) patients co-infected with HIV, (b) patients with concurrent chronic hepatitis B, and (c) patients with uncompensated cirrhosis, not eligible for antiviral treatment with peginterferon and ribavirin. Treatment adherence and the impact of treatment of the quality of life of patients were assessed through standardized questionnaires, using a patient-rated 19 items scale administered at baseline and at 12, 24 and 48 weeks of treatment by the patients’ monitoring physician. Liver fibrosis and inflammation were assessed non-invasively on the Metavir scoring system (FibroTest, Biopredictive, Paris, France). Patients provided blood samples at baseline and each follow-up visit for the following laboratory analyses: liver enzymes – alanine  aminotransferase (ALT) and aspartate aminotransferase (AST) – hemoglobin, white blood cells, platelets, and viral load. Response to treatment was assessed as ‘rapid viral response’ defined as an undetectable viral load after 4 weeks of treatment (RVR), extended RVR at 12 weeks of treatment, and ‘sustained viral response – 24 weeks’ defined as undetectable viral load 24 weeks (SVR-24) after the end of treatment. A number of 78 patients who met the inclusion criteria were considered eligible and enrolled in this non-interventional study. The quality of life during treatment with peg-interferon and ribavirin was assessed through the following questions: ‘How much does the antiviral treatment for chronic hepatitis C affect your life?’, ‘How do you consider that the antiviral treatment for chronic hepatitis C positively influences your life?’, ‘How do you consider that the antiviral treatment for chronic hepatitis C negatively influences your life?’. Statistical analysis All categorical and ordinal variables have been described using univariate and bivariate frequency. Mean variation at each time point compared to baseline was assessed using ANOVA. T-test was used to ascertain the mean difference. The variation of the proportion of normal and abnormal responders at each time point (week 12, 24, 48, and the end of treatment+24 weeks) compared to baseline was assessed using cross-tabulations. Chi squared test was used to assess the statistical significance of percentage differences. P values were considered significant if less than 0.05.

Demographic data

From the 78 included patients 36 (46.15%) were male and 36 (46.15%) female. There are missing data for 6 (7.69%) patients.

In the group of men the mean age was 46.21 (SD=11.41) years ranging between 28-64 years, and in the group of women the mean was 54.04 (SD=8.08) years ranging between 31-65 years. Regarding marital status, 62 patients (80.3%) were married and 56 (72.6%) had children. From educational level point of view, 38 patients (49.3%) graduated high school, 34 patients (43.8%) graduated university, and 5 patients (6.8%) graduated elementary school only. About 72 subjects (93.2%) resided in urban areas.

Patients’ characteristics at baseline and in dynamics

Liver fibrosis and inflammation

Out of 78 patients, for 45 patients the fibrosis Metavir scores and for 28 patients the inflammation degrees were established at baseline. The majority of patients were in stage F3 (19.23%), followed by F2 (15.38%) and F4 (14.1%). Similarly, most of the patients were in stage A3 (20.51%) followed by A1-A2 (7.69%) and A2 (3.85%) (Tables 1 and 2).

Table 1. Fibrosis Metavir score (n=45 patients)

Table 2. Inflammation degree (n=28 patients)

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We recorded data on both liver fibrosis and inflammation for 28 patients (Table 3).

Table 3. Fibrosis Metavir score and inflammation degree (n=28 patients)

Laboratory values analysis

The plasma ALT (n=51) and AST (n=43) were assessed at baseline, with 8 patients (10.26%) presenting normal values of ALT and 43 patients (55.13%) increased values. ALT ranged between 11 and 437 IU/L. Missing data occurred for 27 patients (34.62%). The analysis of plasma AST showed normal values for 10 patients (12.82%) and abnormal values, higher than the upper limit of normal, for 33 patients (42.31%). AST ranged between 21 and 186 IU/L. Normal values for both ALT and AST occurred in 5 patients (6.41%), but 30 patients (38.46%) presented higher values than normal for both ALT and AST (Figure 1).

 

The analysis of hemoglobin values showed that at baseline 48 patients (61.54%) had normal blood levels and only 7 patients (8.97%) lower levels than normal. During treatment with peg-interferon and ribavirin the percentage of patients with hemoglobin levels lower than normal increased. Starting with the 4^th week, 49 patients (62.82%) had lower hemoglobin levels vs 18 patients (23.08%) with normal hemoglobin. At week 12, the number of patients with decreased hemoglobin levels reached the maximum, 62 patients (79.49%), at week 24 52 patients (66.67%), and at week 48 35 patients (44.87%). Six months after the end of treatment 8 patients (10.26%) still had decreased levels of hemoglobin.

The mean value of hemoglobin decreased during the treatment with peg-interferon and ribavirin. At baseline the mean value was 14.65 (SD=1.51) mg/dL, at week 4 12.06 (SD=1.65) mg/dL, at week 12 11.13 (SD=1.48) mg/dL, at week 24 11.60 (SD=1.84) mg/dL, and at week 48 12.27 (SD=1.71) mg/dL. Thus, during the treatment period a decrease of the mean value can be seen from baseline until the 12^th week of treatment followed by a slow increase until week 48^th, the end of the treatment period. Six months after the end of the treatment the mean value was still under the baseline value, being 13.80 mg/dL (SD=1.52). All variations at each follow-up visit during the treatment period and 6 months after end of treatment were statistically significant when compared to baseline (*p<0.001 for all follow-up visits during the treatment period, **p<0.01 at 6 months after the end of treatment) (Figure 2).

 

Figure 2. Hemoglobin mean variation compared to baseline during the treatment period and at 6 months after the end of treatment (*p<0.001, **p<0.01)

 

The same pattern was observed for platelets (thrombocytes) and white blood cells (leukocytes). The percentages of patients with thrombocytopenia and leukopenia increased during the 48 weeks of treatment with peg-interferon and ribavirin. However, the proportion of neutrophils tended to remain normal for the majority of patients.

Viral response

Only 30 patients out of the total number of 78 had plasma viral load determined at baseline and were considered in this sub-analysis as 100%.

At 4 weeks after starting treatment with peg-interferon and ribavirin 13 patients out of 30 (43.33%) obtained RVR (Figure 3) and extended RVR.

 

 

Regarding the sustained viral response at 24 weeks after the end of treatment, the proportion of patients with undetectable viral load was 30% (9 patients out of 30 who provided data about viral load at baseline) (Figure 4).

Figure 4. Sustained viral response at 24 weeks after the end of treatment (n=30)

Peg-interferon and ribavirin doses and treatment adherence

Out of 78 patients participating in this study, 27 patients (34.2%) had been treated before for HCV, while 51 patients (64.6%) were treatment-naïve.

Ribavirin doses ranged between 800 and 1200 mg per day, having a mean value of 1085.33 (SD=104.87) mg. Peg-interferon doses ranged between 100 and 180 μg/week, with a mean value of 165.2 (SD=26.88).

Regarding treatment adherence, from the 78 patients included in this study, at week 12 a total of 73 patients (93.59%) were still under treatment with peg-interferon and ribavirin. The number of patients following peg-interferon and ribavirin treatment decreased during the study period, thus, at week 24 there were 60 patients (76.92%) still on treatment, but at week 48 only 55 patients (70.51%) were still on treatment. From the 23 patients not completing the 48 weeks of treatment 12 were non-responders, 3 partial responders, and 1 had recorded virological breakthrough. Four patients were lost to follow-up and 3 patients withdrew their consent (Figure 5). Only two patients with non-response to antiviral treatment manifested adverse events, which were fever and rash respectively. The patient who experienced virological breakthrough presented fatigue, cough, and rash. From a total of 20 patients manifesting adverse reactions 17 patients continued treatment.

Figure 5.Peg-interferon and ribavirin treatment adherence at week 12, 24, and 48

From 78 patients included in the study 70 received instructions regarding ribavirin and peg-interferon administration. Of these, 52 completed 48 weeks of treatment and 18 interrupted it. Censoring interruptions due to medical reasons such as non-response, partial response and virological breakthrough (n=15 patients), only 3 patients were lost to follow-up despite having received treatment instructions at treatment initiation.

A total of 6 patients didn’t receive instructions at baseline and 2 patients received incomplete instructions, one for ribavirin and the other for peg-interferon only. Only three patients completed the treatment period of 48 weeks from those who did not receive instructions or partial instructions at baseline, the difference being statistically significant (p<0.001).

Quality of life during 48 weeks treatment with peg-interferon and ribavirin

The influence of antiviral treatment on patients’ quality of life was symmetrically distributed between patients who reported no, or minimal interference and patients who reported moderate or high impact 47.44% vs 46.16% at week 12, 39.74% vs 37.18% at week 24, and 30.77% vs 24.36% at week 48 (Figure 6).

 

However, even though the differences are minimal at each time point, the percentages of patients who refused to respond increased from the first visit until the end of the observation period, reaching the level of 44.87% at 48 weeks. Therefore, the results of this analysis should be interpreted with caution.

The perceived positive influence of peg-interferon and ribavirin treatment on patients’ life was mostly due to the following beliefs: ‘It offers me the chance of curing’ followed by ‘It decreases the probability of disease worsening’ (Figure 7).

 

Figure 7.The positive influence of peg-interferon and ribavirin treatment in patients’ life

 

The perceived negative influence of peg-interferon and ribavirin treatment on patients’ life was mostly due to the following issues: ‘Drugs make me feel worse’ followed by ‘Drugs remind me of being sick’ (Figure 8).

 

Through this study we aimed to determine patients` adherence to peg-interferon plus ribavirin antiviral treatment, the viral response, the evolution of laboratory test results of these patients during antiviral treatment, as well as how treatment influenced patients’ quality of life. In this study the number of patients following peg-interferon and ribavirin treatment decreased during the study period, thus, at week 12 there were 73 patients (93.59%) under treatment, compared with 60 patients (76.92%) at week 24 and 55 patients (70.51%) at week 48. The interruption of treatment was in most of the cases due to lack of response (12 cases), partial response (3 cases) and virological breakthrough (1 case). Only 3 out of the  20 patients manifesting adverse events discontinued treatment. In this study, patient counseling regarding treatment administration had an important impact on treatment adherence and specifically on finishing all 48 weeks of treatment, with 74.29% of the instructed patients versus 37.50% of non- or partially-instructed patients completing treatment, p<0.001. Despite the imbalance between these two subgroups (n=70 vs. n=8), there appears to be a clear signal about the importance of therapeutic education with respect to treatment adherence. Our results are also in accordance with data from the literature, which show comparable figures regarding treatment adherence and the impact of treatment education. A study which included 196 African American and 205 Caucasian American adults with chronic hepatitis C reported a rate of treatment discontinuation of 16.5% at week 48, which is lower but comparable with our percentage of 29.49%.7 In a study from Iran on 190 patients the rate of self-reported adherence was 98.42% at 4 weeks, 67.9% at 12 weeks and 32.1% at 24 weeks.8 These results are almost two-fold lower at 24 weeks compared to our study, suggesting the role of patient counseling in tolerating and continuing treatment.  In this study we reported a 43.33% rate of RVR and extended RVR, while SVR-24 was recorded in 30% of cases. In a larger study developed in Italy on 2051 patients, RVR was achieved by 62.2% of patients, and SVR by 50.5% in the retrospective phase and by 38.6%  in the prospective phase.9 In a single center prospective study performed in Poland on 212 patients, 49.5% of those who had received peginterferon plus ribavirin presented SVR.10 Another study performed in Romania reported a 64.9% rate of sustained viral response to antiHCV therapy, which was positively correlated with the presence of HLA-DRB1*11 and 0101 genetic haplotypes.11 The percentages obtained in our study regarding RVR and SVR-24 are lower than those reported in field literature, however, in our study 48 out of the 78 patients enrolled had missing data regarding viral load at baseline, and therefore couldn’t be included in the analysis. Moreover, data on IL28-B polymorphism was not available in our study and therefore a clear differentiation of the reason for failing to obtain SVR cannot be established at this point. Importantly, response to therapy has been significantly associated with a reduction in liver fibrosis,12 allowing a regeneration of the liver with potential return to its pre-infection state, particularly when treatment is started earlier. In our study the percentages of patients having their life quality not influenced or slightly affected by antiviral treatment with peg-interferon and ribavirin were almost equal with those having their quality of life influenced in different degrees by this treatment, even though the percentages of patients declaring a good quality of life were constantly higher in comparison with those having a decrease in the quality of life. Multiple studies performed in developed countries showed that chronic hepatitis C is associated with a considerable impairment of health-related quality of life.13-19 Our study does not enter in conflict with the above observations, as we had a similar distribution of patients reporting impairment in terms of quality of life, or lack thereof. However, in our study the percentages of missing data are relatively important and could influence some of these results. Our study highlights the importance of counseling patients regarding the correct administration of treatment and about the adverse events that may occur.

In patients with chronic hepatitis C treated with peg-interferon and ribavirin in Romania, treatment adherence reached relatively high levels, constantly over 70%, and was statistically associated with pre-treatment counseling regarding the correct administration of the medication.